Please Complete The Following Consent Form
The purpose of this consent form is to provide written information regarding the risks, benefits and alternatives of treatment with Kybella. This material serves as a supplement to the discussion you have with your Bloom Health provider. It’s important that you fully understand this material, so please read this information thoroughly. If you have any questions regarding the procedure, ask your Bloom Health provider prior to submitting this consent form.
TREATMENT GOALS AND DESCRIPTION OF PROCEDURE
Kybella (deoxycholic acid) injections are indicated for improvement in the appearance of moderate to severe fullness below the chin (submental fat) in adults. Kybella is a cytolytic drug, which when injected into tissue physically destroys the cell membrane causing lysis. Your provider will inject small 0.2 cc amounts of Kybella into the target area, using up to 50 injections during a single treatment. This procedure is not a treatment for obesity or a weight-loss solution. The treated area may develop swelling, tenderness, numbness or bruising in the days and weeks following treatment. These are normal reactions that typically resolve within days to weeks.
Most patients are pleased with the results of their Kybella treatment. However, like any aesthetic procedure, there is no guarantee that you will be completely satisfied. There is no guarantee that the treated fat area will disappear completely, or that you will not require additional treatment to achieve the results you seek. Multiple treatments are usually needed to achieve a full effect, with a usual recommendation of 2-6 treatments, spaced about 4 weeks apart. The results of treatment are dependent on many factors including but not limited to: age, tissue conditions, and your general health and lifestyle conditions. Results may be visible as early as 3 weeks after your Kybella procedure, and you will experience the most dramatic results after 2-4 months. Your body will continue to naturally process the treated fat cells from your body for a few months after your procedure. Although highly unlikely, it is possible that you will not achieve any noticeable result from the procedure.
Following your Kybella procedure, we’ll provide you with verbal and/or written aftercare instructions. These include, but may not be limited to the following: 1) You may resume normal activities immediately following the procedure; 2) Okay to apply ice and take Tylenol, NSAIDs, or oral arnica for post treatment discomfort; 3) You may experience temporary pain, redness, swelling, or bruising for up to 4-6 weeks; 4) You may experience temporary numbness in the treated area, which can last up to 6 weeks; 4) In rare cases, you may experience open sores, ulcers, drainage or damage around the injection site in which case you should notify your BLOOM HEALTH provider; 6) If at any time you suspect you’re having an unexpected side effect, adverse reaction or complication, contact us immediately, and obtain help in an appropriate medical setting (i.e., BLOOM HEALTH, your primary care provider, specialist, urgent care, or acute care facility). I will adhere to the aftercare instructions supplied to me during my visit.
POTENTIAL RISKS AND COMPLICATIONS
Before undergoing this procedure, understanding the risks is essential. The following risks may occur, but there may be unforeseen risks and risks that are not included on this list. Some of these risks, if they occur, may necessitate hospitalization, and/or extended outpatient therapy. I understand that there are certain inherent and potential risks and side effects in any procedure, and in this specific instance such risks include but are not limited to: 1) Injection site reactions, including edema/swelling, hematoma/bruising, pain, numbness, erythema, induration, paresthesia, nodule formation, pruritus, and skin tightness; 2) Dysphagia, or difficulty swallowing; 3) Nerve injury, including marginal mandibular nerve injury which may temporarily paralyze muscles around the mouth area ; 4) Injury to nearby anatomic structures, such as lymph nodes, salivary glands and muscles; 5) Injection site alopecia; 6) Injection site ulceration and necrosis. In rare cases, surgical intervention may be required to address these problems.
PREGNANCY AND CONTRAINDICATED CONDITIONS
I am not aware that I am pregnant. I am not trying to get pregnant. I am not lactating (nursing). I have notified my Bloom Health provider of any previous or planned surgical procedures to the face, neck , chin or other area to be treated. I do not have any difficulty swallowing or any bleeding problems. I am not on anticoagulants or antiplatelet medications. I do not have known sensitivity to Kybella. I do not have an infection in the treatment area.
I understand that this is an elective procedure with goal of improved aesthetic appearance and that the main alternative to therapy is to observe and not receive any treatment. Other therapies for fat reduction might include cryolipolysis or surgical liposuction.
I understand that Kybella treatment is not covered by insurance, and payment is my responsibility and is expected at the time of treatment.
RIGHT TO DISCONTINUE TREATMENT
I understand that I have the right to discontinue the procedure at any time.
RELEASE OF LIABILITY
I hereby indemnify Bloom Health, PLLC from any liability relating to the procedures that I have volunteered for. I understand that any treatment performed is between me and the doctor/healthcare provider who is treating me and I will direct all post-treatment questions or concerns to the treating clinician. Furthermore, I hereby indemnify the facility/meeting room/hotel where this treatment is being performed from any liability relating to the procedures that I have volunteered for.
CONSENT TO TREATMENT
By entering my initials below, I hereby voluntarily consent to treatment with Kybella for the purpose of fat reduction in the submental area, or other planned areas, as performed by my Bloom Health provider. I have read the above and understand it. I state that I read and write in English. I am not under the influence of drugs or alcohol. The treatment has been fully explained to me and my questions have been answered satisfactorily. I accept the risks and complications of this elective procedure and I understand that no guarantees are implied as to the outcome of the procedure. Please note this consent is valid for all future Kybella treatments I choose to receive from Bloom Health.